When Medical Progress is not Enough

In this article in the NYT from a few weeks back, there is this quote from Dr. Stefano Bertozzi, director of H.I.V. and tuberculosis for the Bill and Melinda Gates Foundation:

“That we have men that are willing to be circumcised and we haven’t been able to mobilize the resources to get them circumcised — it’s really inexcusable that it’s taking as long as it is. This is the equivalent of a 60 percent effective vaccine for men. It’s my No. 1 priority in Africa. It’s clearly the most obvious, most cost-effective intervention we could use to dramatically change the course of H.I.V. in the near future.”

The article goes on to talk about various obstacles responsible for the fact that only 600,000 men out of the more than 20 million men, aged 15-49 in 14 African countries, have been circumcised so far: “a dearth of political or logistical support from governments and traditional leaders; cultural misconceptions; and in some places requirements that doctors, not nurses or physician assistants, perform circumcisions.”

It is not clear, however, neither from the article nor from the research I have seen, that the problem is supply side. Dr. Bertozzi’s statement implies that there are masses of men out there waiting to be circumcised but the governments and the international donor community cannot get its act together. I am sure there are some people who are frustrated by the system and are still uncircumcised as a result. But, what about the masses that are not (but could be) convinced that they should get circumcised?

In my opinion, we need two things at this stage. First, we need carefully designed studies to figure out effective ways to increase take-up. These would presumably be combining demand- and supply-side interventions and would vary slightly across countries. I understand that time is if the essence, but trying to figure out why people are not taking up this 60% effective vaccine in an unsystematic manner does not seem to be working. We may be better off designing some carefully coordinated RCTs in a bunch of countries and scale-up successful strategies, just like those studies that convinced many that circumcision works in the first place. But, economists will have to get involved in these studies as it is not the forte of the biomedical research community to figure out how to increase take-up.

Second, we have to fight the opposition in many places to pay people to get circumcised. These can be in kind or cash payments totaling substantially less than the savings (presumably billions of dollars) from the future infections averted. Cultural sensitivities are important of course and have to be observed, but we cannot just rule out an intervention that is potentially very effective from the outset. Perhaps demonstrations in some places would serve to convince others that this may be a feasible avenue.

Incentives to get circumcised also have the advantage of helping with selection problems. Currently, it is not clear what the profile of people getting circumcised is, and whether the benefits realized in the RCTs will materialize as MC is scaled up. Incentives (and information, etc.) would bring those who would otherwise choose to go uncircumcised into the mix.

I have much more to say about the roles of medical vs. economic RCTs, but that will make this too long a post, so I leave it for another post the near future. In the meantime, I leave you with my predictions for the semifinals in the Rugby World Cup this weekend: Wales over France and New Zealand over Australia.

Michelle Poulin and I have a paper under review about ethnoregional patterns of attitudes toward male circumcision in Malawi. (I'd share the draft but have learned my lesson on posting working papers online). At least in the Malawian case, I think the demand side is part of the problem. Essentially, we find that the respondents with positive opinions of male circumcision draw largely from the one ethnic group in Malawi that regularly includes male circumcision in coming-of-age ceremonies. Ethnic others generally have negative opinions.
In our paper, we cite a report from Nyanza (Kenya) that has been experiencing greater success with demand for their medical male circumcision campaign. In a project with Michelle and Lauren Gaydosh, we hope to uncover more of what we think is driving these differences between Kenya and Malawi (with analysis that also considers Zambia and Uganda).